Organised By:
select an option:
Public Health Dentistry:
Others:
Department
Date :
Place :
District :
Name :
Age :
Contact :
Education :
Gender :
Male
female
Others
Monthly income of family :
Chief Complaint
Past Medical History
Diabetes
Yes
No
HyperTension
Yes
No
Thyroid disorders
Yes
No
Cardiovascular diseases
Yes
No
Respiratory diseases
Yes
No
Bleeding disorders
Yes
No
Others:
Past Dental Visit
Yes
No
Personal Habits
Smoking
Yes
No
Alcohol
Yes
No
Smokeless Tabacco
Yes
No
Others:
Clinical Examination
Decayed:
Missing:
Filled:
Pain:
Fractured teeth:
Mobility:
Others:
Gingiva
Calculus:
Yes
No
Stains:
Yes
No
Chronic gingivitis:
Localized
Generalised
None
Chronic periodontitis:
Localized
Generalised
None
Dental Fluorosis
Yes
No
Malocclusion
Yes
No
Oral mucosal lesion
Method of cleaning teeth
select an option:
toothbrush and paste:
Finger:
tooth powder
natural stick
Others:
Others:
Doctor's Name :
Treatment Plan
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Medication:
Referral:
Scaling:
Extraction:
Filling:
Nil:
Others:
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